DESIGNED TO PRIME RELATED INSIGHTS - MANAGEMENT AND EVIDENCE List of Editorial Board

1. Mr. Prakash PVS – Consultant Chief Perfusionist at Narayana Hrudayalaya, Bangalore

2. Mr. Bhaskaran Vishwanathan – Chief Perfusionist at Madras Medical Mission Hospital, Chennai

3. Mr. Atul Solanki – Chief Perfusionist at U. N. Mehta Hospital, Ahmedabad

4. Mr. Manoj MC – Perfusionist at Kokilaben Dhirubhai Ambani Hospital, Mumbai

5. Mr. Navin – Perfusionist at Jaslok Hospital, Mumbai

6. Ms. Kamla Rana – HOD Perfusion Department at Medanta - The Medicity, Gurgaon, Haryana (NCR Delhi),

7. Mr. Bijender Singh Bali – Chief Paed. Perfusionists – For�s Escorts Heart Ins�tute & Research centre Editorial Letter

Dear Readers,

PRIME – 'Perfusion Related Insights - Management and Evidence' is a scien�fic newsle�er published every quarter with the help of our editorial board members and includes latest reviews, guidelines and expert experiences in rela�on to perfusion strategies.

We are happy to present the 1st issue of PRIME to you.

The 'Review Ar�cle' sec�on in this issue includes an important publica�on on the use of prescrip�ve pa�ent extracorporeal circuit and sizing during adult . In this ar�cle, Bronson SL, et al. discusses how the use of the 'right- sized' circuit algorithm may be useful in elimina�ng allogeneic blood transfusions in ..

This publica�on also includes two expert experiences shared on ‘Cardiopulmonary bypass during pregnancy' and 'Perfusion strategies in arch repair', from two of our editorial board members.

The first contribu�on showcases two cases in the second trimester of pregnancy undergoing , in which the fetal heart rate and umbilical artery flow velocity were con�nuously monitored by transvaginal ultrasonograpy and analyzed in rela�on to the events of the cardiopulmonary bypass.

The second contribu�on presents the procedure of arch repair on low flow bypass or total circulatory arrest with intermi�ent perfusion.

The 'Guidelines' sec�on touches upon the 'Development of Ins�tu�onally based Protocols', as advised by the AmSECT Standards and Guidelines for Perfusion Prac�ce, 2013. This guideline by ICEBP aims to provide a framework to guide the safe and effec�ve prac�ce of cardiopulmonary bypass in adult pa�ents.

We hope PRIME will create an awareness among perfusionists and will serve the purpose of being a publica�on alert for the experts. We are looking forward to hear from you for your valuable feedback, comments and sugges�ons.

Dr. Sandeep Arora Head Medical Affairs Terumo India Pvt. Ltd. On behalf of editorial board members DESIGNED TO PRIME PERFUSION RELATED INSIGHTS - MANAGEMENT AND EVIDENCE

SECTION 1 REVIEW ARTICLE

Use of prescrip�ve pa�ent extracorporeal circuit and oxygenator sizing during adult cardiac surgery

Introduc�on Average OR Hgb nadir over the nine quarters and the % increase in pa�ents receiving no transfusions in the The current quality improvement project is aimed at reducing OR and ICU the prime volume of the cardiopulmonary bypass (CPB) FIGURE 1 circuit by matching , reservoirs, and arterio- Hgb Nadir g/dL 8.9 venous (A-V) loops to pa�ents, on the basis of pa�ent blood 8.8 8.7 flow requirements during CPB. A hypothesis was made that 8.6 8.5 p<0.0001 by decreasing the prime volumes for smaller body surface /dL g 8.4 area (BSA) pa�ents, the hemoglobin (Hgb) nadir would 8.3 8.2 increase, which would help to reduce allogeneic red blood cell 8.1 (RBC) and blood product transfusions. 8.0 % Receiving no transfusion 60 Methods 55

t 50 An observa�onal analysis of 3,852 adult cardiac surgical n p=0.0108 ce 45 e r pa�ents who underwent CPB in an ins�tu�on (between P 40 January 1, 2011 and March 31, 2013) was used for this quality 35 30 ini�a�ve. Using a sizing algorithm - derived from manufacturers' recommenda�ons - individualized "right- 2011-Q1 2011-Q22011-Q3 2011-Q4 2012-Q12012-Q22012-Q32012-Q42013-Q1 Year and quarter sized" extracorporeal circuits was created, based on the pa�ents' BSA, cardiac index and target blood flows. Because of the usage of right-sized algorithm, pa�ents with Results similar BSA, who were previously exposed to larger oxygenators, reservoirs, and arterial-venous loops, were now Use of a sizing algorithm led to an increase in the percent of supported with smaller circuits. The algorithm was adjusted algorithm-recommended smaller oxygenators being used for unique cases and procedural situa�ons, including age, from 39% to 63% (p<0.01) and an increase in average Hgb gender, and length and type of procedure. Larger heat nadir from 8.38 to 8.76 g/dL (p<0.01) (Figure 1). The marked exchanger surface area oxygenators were used for circulatory increase in the average Hgb nadir helped to decrease the arrest procedures, due to requirement for increased heat usage of blood in the opera�ng room (OR) and surgical exchange capability. Reduced transfusion related intensive care unit (ICU) (Figure 1). A significant increase was expenditures and decreased exposure risks jus�fied the use of noted in the percent of the pa�ents who did not receive a smaller circuit components, despite its higher costs. transfusion over the period of nine quarters.

Use of the “right-sized” circuit algorithm may be useful in increasing Hgb nadir during USION CPB and eliminating allogeneic blood transfusions in cases undergoing CPB. ONC L C

Source: Bronson SL, Riley JB, Blessing JP, Ereth MH, Dearani JA. Prescrip�ve pa�ent extracorporeal circuit and oxygenator sizing reduces hemodilu�on and allogeneic blood product transfusion during adult cardiac surgery. J Extra Corpor Technol. 2013;45(3):167-72.

4 DESIGNED TO PRIME PRIME PERFUSION RELATED INSIGHTS - MANAGEMENT AND EVIDENCE

EXPERT EXPERIENCES SECTION 2

Contributed by: Dr. Kamla Rana HOD Perfusion Department at Medanta - The Medicity, Gurgaon, Haryana (NCR Delhi), India

Case 1: Cardiopulmonary bypass during pregnancy Kamla Rana, Arya Khare, R. P. Singh, Rohit Srivastava, S. M. Khalid, L. K. Srivastava, Dr. Vijay Kohli, Dr. R. K. Bapna, Dr. Manisha Mishra, Dr. Naresh Trehan Department of Cardiothoracic and Vascular Surgery, Medanta - The Medicity, Gurgaon, Haryana, India

Introduc�on mitral regurgita�on, along with a clot in the le� atrial appendage on transthoracic echocardiography. We report two cases in second trimester of pregnancy undergoing mitral valve replacement, in Case II – A 26-year-old gravida II para I was admi�ed with which the fetal heart rate and umbilical complaints of breathlessness on exer�on at 17 weeks of artery flow velocity were con�nuously gesta�on, with severe mitral stenosis, moderate tricuspid m o n i t o r e d b y t r ansvaginal valve regurgita�on, along with moderate pulmonary artery ultrasonograpy and analyzed in rela�on hypotension (PAH). to events of the CPB. Surgery was the only op�on at this stage of gesta�on in both 2 Materials and methods the pa�ents. During CPB, a high flow rate (2.5 L/min/m ), perfusion pressure >70 mmHg, normothermia, maternal Case I – A 33-year-old gravida III para II hematocrit >28%, and pulsa�le perfusion were maintained. was admi�ed to our ins�tute at 16 Umbilical artery flow velocity waveforms were recorded. The weeks of gesta�on with acute pulsa�lity index (PI) and resis�ve index (RI) values were s h ortness of b r e a th and calculated. palpita�on, with a thickened heavily calcified mitral valve and a moderately severe eccentric jet of

>> The most important event during surgery is the transition of circulation from corporeal to S

T extracorporeal; the decrease in mean arterial pressure (MAP) at this stage may have potential deleterious effects on the fetus and should be avoided

>> It is advisable to go initially on partial CPB and then slowly on full CPB, maintaining high MAP and avoiding the use of vasoconstrictors, which may have a profound effect on the placental unit

ARNING POIN >> Maternal and fetal monitoring can enable early recognition of potential problems during CPB and L E timely provision of the required treatment

5 DESIGNED TO PRIME PERFUSION RELATED INSIGHTS - MANAGEMENT AND EVIDENCE

Contributed by: Manoj M C Chief Pediatric Perfusionist at Kokilaben Dhirubhai Ambani Hospital and Medical Research Ins�tute, Mumbai

Case 2: Perfusion strategies in arch repair Manoj MC, Jinil Raj TS, Sujit Bamne, Dr. Shankar Kadam, Dr. Kamlesh Tailor, Dr. Simran Kundan, Dr. Bipin Radhakrishnan, Dr. Smru�ranjan Mohanty, Dr. Suresh G. Rao Kokilaben Dhirubhai Ambani Hospital, Mumbai, India

Arches are repaired on >> The ductus is divided; the juxtaductal aor�c dissec�on is low flow bypass or total completed. The ductus is interrupted and ligated. The circulatory arrest (TCA) descending aorta distal to the ductus is occluded with a with i ntermi� e n t spoon clamp, the arch branches are occluded with perfusion. aneurysm clips, and the arch itself is occluded with an angled clamp, just distal to the innominate. This leaves Procedure the arterial cannula perfusing the cerebral and coronary >> A�er sternotomy circula�ons and we reduce the flows to about and the basic 50 ml/kg/min dissec�on, aor�c >> The arch reconstruc�on is started. The ascending aorta is cannula�on is done clamped proximal to the cannula, and the heart is with a single purse arrested with antegrade blood cardioplegia string, with the �p of the cannula just >> The flows for the arterial cannula are reduced to into the lumen of 30 ml/kg/min for selec�ve cerebral perfusion. Once the the aorta by 2-3 mm arch repair is finished and perfusion is re-established, rewarming is started >> A 14 or 16 Fr straight cannula is used for venous drainage >> Once TCA �me exceeds 40 minutes, we re-perfuse at low >> Once bypass is ins�tuted, the flow is maintained at 2.4 flows, for every 10 minutes of TCA �me, we perfuse for 1 liter/kg/min, which translates into a flow rate of about minute. At no point does the TCA �me extend 175-200 ml/kg/min uninterrupted for more than 40 minutes >> The stringent �me frame for core cooling �me is 20-30 >> Rewarming is started, in coordina�on with the procedure minutes which is very important to let the bradycardia set in gradually, reduce the metabolism of the heart, maintain no gradient or a gradient of less than 2 degree cen�grade between the rectally recorded and peripherally recorded temperatures

6 DESIGNED TO PRIME PERFUSION RELATED INSIGHTS - MANAGEMENT AND EVIDENCE

GUIDELINES SECTION 3

American Society of ExtraCorporeal Technology Standards and Guidelines for Perfusion Prac�ce (2013): Report from the Interna�onal Consor�um for Evidence-Based Perfusion (ICEBP)

Standard and guideline for checklist The perfusionist should use checklists for each CPB procedure which should be a part of the pa�ent's permanent medical record in a read-verify manner where the cri�cal steps that needed to be performed should be confirmed. The checklist should be completed by two people out of whom one person should be the primary perfusionist who is responsible for opera�on of the heart lung machine during the procedure. The checklist should be used during the en�re periopera�ve period. Perfusionist should use the checklist also for other ancillary perfusion services. Standard and guideline for communica�on A pa�ent-specific management plan for the CPB procedure should be prepared and communicated to the surgical team at the �me of preopera�ve briefing or before the start of procedure. The use of cellular telephone technology in the procedure room should be guided by the principles of the ST-59 Statement on use of cell phones in the procedure room wri�en by the American College of Surgeons. Protocol-driven communica�on should be used to acknowledge the verbal commands, verify the content, and reduce ambiguity. The primary perfusionist should take part in the post-procedure debrief with the surgical team.

NEWS UPDATE SECTION 4 A�enua�ng the Systemic Inflammatory Response to Adult Cardiopulmonary Bypass Numerous approaches have been studied to a�enuate the evidence for minimizing inflamma�on included nitric oxide systemic inflammatory response to CPB; however, there is no donors, C1 esterase inhibi�on, neutrophil elastase inhibi�on, systema�c based review which covers the scope of an�- propofol, propionyl-Lcarni�ne, and intensive insulin therapy. inflammatory interven�ons deployed. Thus, an evidence- A secondary analysis showed that suppressing at least one based review was conducted to capture “self-iden�fied” inflammatory marker is necessary, but not sufficient to confer an�-inflammatory interven�ons among adult CPB clinical benefit. The most effec�ve interven�ons were those procedures. This review iden�fied 33 different interven�ons which targeted mul�ple inflammatory pathways. and approaches to a�enuate the systemic inflammatory response. But very few papers (35 of 98) showed any clinical There is a need of further research to evaluate whether improvement to one or more of the predefined outcome combina�ons of interven�ons which target mul�ple measures. inflammatory pathways are capable of synergis�cally reducing inflamma�on and improving outcomes a�er CPB. Interven�ons at level A evidence included off-pump surgery, minimized circuits, biocompa�ble circuit coa�ngs, leukocyte Source: Landis RC, Brown JR, Fitzgerald D, Likosky DS, Lesserson LS, Baker RA, et al. A�enua�ng the systemic inflammatory response to adult filtra�on, complement C5 inhibi�on, preopera�ve aspirin, cardiopulmonary bypass: A cri�cal review of the evidence base. JECT. and cor�costeroid prophylaxis. Interven�ons at level B 2014;46:197-211.

7 h Copyrig Disclaimer: means pr Dev escribing in escribing eloped andDesignedby electr t:

All This onic, f righ orma

ma ts

mechani �on. Please r �on. t r erial eser v is ed. c

al, pr

No ovided pho ead the full pr ead thefull part t oc by of opies, this T erumo

prin r e c escribing in escribing or t as publi ding pr

of or ca�on essional otherwise, f orma

ma y �on ser be

without vice r epr f or app t oduced, o the

the r ov medi wri� ed in s t or c en f ed al orma permission c in ommunit

r �on on an on �on etriev al y

of s . y Inf

stem, y pr Insignia, orma oducts discussed in this publi this in discussed oducts

t apes, �on Mumbai.

r

discs, ela t ed

micr t o an ofilms, y pr oduct(s)

e t c., c a or �on and be and �on tr ma ansmi� y not

ed be f or in e pr c sten onsi

an escribing. y f orm t or with by

an the y

For the use of a registered medical prac��oner or a hospital or a laboratory only